Please enable JavaScript in your browser to complete this form.Tutoring Request Form Fall 2024 Full Name *FirstLastSex *_MaleFemaleEthnicity *_Black/African AmericanCaucasianHispanicAsianOtherAddress *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of Birth *Current Grade *School Currently Attending *What Subject do you need help *Medical Conditions/Allergies *Parent/Guardian Information Parent/Guardian Name *FirstLastPhone *Email *What Subject you need help inMathReadingHow did you hear about our program? *Do we have permission to contact you VIA text message? *YesNoPart A: Release/Liability *In case of an emergency injury or illness, I authorize ABC youth Program to call the paramedics. As legal guardian of the above listed student, a minor, I authorize the ABC representative designee to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis, treatment, and/or hospital care to be rendered upon the advice of any licensed physician and/or dentist.I give my consent to ABC youth Program to allow my child to use the internet under the supervision of the ABC Staff.I hereby give ABC youth Program (ABC) and its partners and affiliates consent to use and reproduce my child’s first name/image for promotional purposes relate to ABC, and/or external partners. My child’s first name (unless otherwise authorized)/image may be published or used in newspapers, promotional videos, television commercials, program brochures, posters, on World Wide Web or otherwise displayed to the public or used for other educational/fundraising purposes, either in whole or in part by ABC, or external partners. I release ABC and its agents from any and all claims, of any nature, based on any uses of the above.In consideration of the risk of injury while participating in ABC youth Program (the “Activity”), and as consideration for the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive and all rights, claims or causes of action of any kind whatsoever arising out of my child’s participation in ABC youth Program, and do hereby release and forever discharge ABC youth Program, located at 2715 North Averill Avenue, Flint, Michigan 48506, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors, and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in ABC youth Program, including traveling to and from an event related to ABC youth Program. I agree to indemnify and hold harmless ABC youth Program against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney’s fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf. If ABC youth Program incurs any of these types of expenses, I agree to reimburse ABC youth Program. I acknowledge that ABC youth Program and their directors, officers, volunteers, representatives and agents are not responsible for errors, omissions, acts or failures to act of any part or entity conducting a specific event or activity on behalf of ABC youth Program. A parent/guardian is required to attend a parent meeting before the youth can participation in the summer program.Electronic Signature *FirstLastSubmit
